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  • Low-dose steroids lose efficacy in patients with concurrent dry eye and GVHD

    Cornea/External Disease

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    This study compares the efficacy of topical steroids in patients with dry eye disease (DED) who do or do not have underlying graft-vs-host disease (GVHD).

    Study design

    This prospective, ad hoc analysis of a prior randomized trial examined 42 patients with moderate to severe DED, including 21 patients with chronic GVHD. All patients received loteprednol etabonate 0.5% ophthalmic suspension or artificial tears, twice daily. Patients underwent a masked ophthalmic evaluation prior to starting the regimen and were reevaluated 4 weeks after treatments.

    Outcomes

    The groups had similar signs and symptoms of DED at baseline. In the non-GVHD group, loteprednol use decreased the Ocular Surface Disease Index (OSDI) score by 34% (P=0.001) and the corneal fluorescein staining (CFS) score by 41% (P=0.016). Artificial tears decreased the CFS but did not alter any other parameters.

    In the GVHD group, loteprednol decreased the Schirmer test scores (P=0.043) but did not affect OSDI or CFS scores (P=0.66 and 0.85, respectively). Artificial tears produced no significant changes in this group.

    Limitations

    This small study showed a trend toward greater use of autologous serum tears in the GVHD group at baseline than the non-GVHD group, though this trend was not statistically significant. The GVHD also had a higher OSDI score at baseline compared with the other group. The authors suggest this finding may indicate that the GVHD group included patients with more advanced illness at baseline compared with the non-GVHD group. Also, given the propensity for ocular GVHD to produce lacrimal gland fibrosis, it is possible that the lacrimal gland is no longer an effective target for steroids.

    Clinical significance

    This study demonstrates that moderate DED secondary to GVHD does not respond as readily to low dose steroid therapy as non-GVHD associated dry eye. These findings suggest that either more aggressive steroid therapy may be needed, or alternatives to topical steroids should be considered in this more advanced group of dry eye patients.